Axillary Lymph Node Presentation with Occult Breast Carcinoma

ABSTRACT

A palpable breast lump is the most frequent symptom of breast cancer. At the same time, metastatic lymph nodes can be palpable in the axilla. Breast cancer can sometimes present as an isolated axillary adenopathy without any clinically detectable breast tumor. The incidence of an occult primary tumor with axillary metastases is very low, 0.4% of the breast cancer patients in the collective data. A metastatic carcinoma found in an axillary node should be treated as a breast cancer, because the breast is the most common primary site and because breast cancer is a curable disease with proper management. Between July 1993 and June 1996, 523 breast cancer patients underwent surgery in Asan Medical Center. Among them, 7 patients (1.3%, 7/523) presented with metastatic axillary lymphadenopathy without clinical evidence of a breast tumor or any other primary tumor. The median age of these 7 patients was 49 years (range 39~62 years). The mean size of palpable lymph nodes was 3.7 cm. A histological diagnosis of metastatic adenocarcinoma was obtained by excision in 5 patients and by fine needle aspiration cytology in 2 cases. The findings of the preoperative mammography was normal in 5 patients showed a dense breast in one patient was suspicious in one patient (14%, 1/7). Preoperative ultrasonography detected a suspicious tumor in two patients (28%, 2/7). The primary treatment was a modified radical mastectomy in 6 patients and an axillary dissection with whole breast radiotherapy in one patient. A breast cancer was found in the mastectomy specimen of 4 of 6 patients (66%) one invasive ductal, one invasive lobular, one DCIS, and one LCIS tumor. No tumor was found in two mastectomy samples.The median number of involved metastatic lymph nodes was 2 (range 1~25). The staging was IIA (TxN1M0, T0N1M0) in 4 patients, IIB (T2N1M0) in 2 patients, and IIIA (TxN2M0) in one patient. Four patients were positive for hormone receptors, 2 were negative, and one was unknown. All the patients were treated with postoperative adjuvant chemotherapy, radiotherapy or hormone therapy; no recurrence has been found in these patients to date. We conclude that axillary metastases without clinical evidence of a primary breast tumor represents a unique clinical entity of breast cancer, and it should be treated as a breast cancer to avoid unnecessary labaratory or radiological efforts to find the primary site.